Provider Demographics
NPI:1487251989
Name:NYAMU, JUANETTA MADRE (LLPC)
Entity type:Individual
Prefix:
First Name:JUANETTA
Middle Name:MADRE
Last Name:NYAMU
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 TORREY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3327
Mailing Address - Country:US
Mailing Address - Phone:810-494-7180
Mailing Address - Fax:810-215-1334
Practice Address - Street 1:1701 LAKE LANSING RD STE 120
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3798
Practice Address - Country:US
Practice Address - Phone:810-494-7180
Practice Address - Fax:810-215-1334
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401019456101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional